The Benefits of Formal Manual Handling Healthcare Programmes - Literature review Example

What are the benefits and predisposing factors to success of formal manual handling healthcare programmes to healthcare workers? Objectives:To determine the effectiveness of manual handling programmes in minimising work-related injuries and the benefits and predisposing factors for the success in healthcare workers. Methods: A literature search strategy of 30 studies and the use of CASP’s systematic review tool as guide. Results: Formal manual handling programmes are intended to minimise the dangers of manual handling in the healthcare profession, but it is uncertain whether these programmes became effective or not. The implementation of the Manual Handling Operations Regulations 1992 and other localized programmes had been formulated to address the increasing incidences of work-related injuries in manually handling patients, however, there is little evidence to support the effectiveness of those programmes in a long-term basis, and counter-evidence was even found. Conclusion: Further researches on these programmes are necessary to investigate the effectiveness of formal handling programmes, more specifically, long-term follow-up studies. Introduction Healthcare workers and manual therapists often encounter work-related injuries directly resulting from manual handling of patients in the workplace. Though formal manual handling programmes were introduced in effort to minimize work-related injuries, beginning from The Manual Handling Operations Regulations 1992 to other additional enhanced programmes to minimize work-related injuries, the effectiveness of such programmes needs to be assessed in the field of healthcare and manual therapy. A previous study had been conducted by the researcher to precisely reveal the nature of injuries sustained from direct manual handling of patients. Since the most common problems encountered by these manual therapists were musculoskeletal in nature such as pain and injuries in the lower back, wrists, hands, fingers, shoulders, and neck, there is a shadow of doubt whether the formal programmes really do minimized the work-related injuries or not at all in the field of health care, since these programs are intended to minimise musculoskeletal injuries. As a sequel to the previously made research, after obtaining proof that work-related injuries are still an unresolved threat to manual therapists, this study will further investigate whether the introduction of formal manual handling programmes are indeed effective or not by exploring related studies conducted within the past 15 years, a time span reasonable enough for employers to adjust their working conditions in compliance to The Manual Handling Operations Regulations 1992 and other programmes. This study will investigate the frequency of studies being made to assess how work-related injuries are minimised through the implementation of formal manual handling programmes. The respective qualities of these studies shall be assessed and whether they are relevant to manual therapy practice. Results obtained from these studies will be analysed and will offer recommendations of improving manual therapy practice while minimising work-related injuries. This will serve as a future guide for healthcare practitioners and also to motivate future researchers to conduct further studies on the effectiveness of these formal manual handling programmes and future developments in enhancing the safety in the health care industry. Methodology To obtain supportive information in carrying out a well-panned literature search, a search strategy was planned to search for CINAHL, MEDLINE, SportDiscuss and Ahmed databases via Keele University Library. Science Direct was also included in the database search. Google Scholar and i-scholar search engines were also utilized. Table 1 displays the combination of search terms applied, while a sample search history can be found at Appendix 1 of this paper. Search Terms Osteopathy Chiropractor Manual therapist Nurse Physical therapist Manual handling The term ‘and’ ‘or’ inserted Injury in the workplace Occupational injury Risk factors Risk management Occupational health Table 1. Search Terms used in locating the best available evidences through literature search strategy. Source: Author (2010) To strengthen the focus and relevance of the literatures, inclusion and exclusion criteria were applied to the search strategy, summarized at Table 2. Studies recently conducted within fifteen years (Year 1995-2010) are included. Several manual therapy professions (e.g. nursing) were also included to provide an overview of the effectiveness of formal manual handling programmes. Additional information discussing potential casualties of work-related injuries without the discussion of how formal manual handling programmes influenced the study participants were also included. Non-English articles were excluded from the search. Inclusion Criteria Exclusion Criterion Recently conducted within fifteen years Manual therapy professions Articles discussing work-related injuries in manual therapy positions even if no discussion of the relevance of formal manual handling programmes Non-English articles Table 2: Inclusion and exclusion criteria used in the literature search strategy Study Selection Process Figure 1 presents a flow diagram on how the 30 included articles were selected from the database search. Figure 1. Inclusion Criteria versus Exclusion Criteria Following the selection process it was noted from the abstracts and titles that the papers could be further subdivided into more specific areas of research: 1. Results of research into manual handling programmes aimed specifically at areas of injury. i.e. Low back pain, thumb pain, neck and shoulder pain. 2. The results of the implementation of programmes after a follow-up period: Has intervention helped? 3. Research into what a manual handling programme should consist of. Selected literatures passing the inclusion and exclusion criteria were divided into three groups highlighted for ease of reference (Table 3). In order to evaluate the quality of the papers being reviewed the papers were quality rated using a quality rating tool as that supplied by the University and recommended for use. Fifteen studies are ranked Excellent, those that are well-designed and executed study, with care taken to avoid bias and have very few weaknesses. Eleven studies are ranked Good, having reasonable study design with minor flaws or omissions. The remaining four studies are ranked Fair, having flaws and limitations in design, so conclusions to be viewed with caution, yet strengths and weaknesses equally balanced. The Systematic Review Tool of the Critical Appraisal Skills Programme (CASP) guidelines was utilized as this study was conducted (see Appendix II). Author Title Quality Rating Method Health Care Worker Results 1. Iakovou, G.T. (2008) Implementation of an evidence-based safe handling and movement mobility curriculum in an associate degree nursing program Fair Quantitative Student nurses Early training decreased chances of incurring future work-related injuries. 2. Donnelly, C. & Macmillan M.S. (2007) Devising and evaluating a model for teaching therapeutic handling and moving skills to complementary therapists Good Mixed Methods Complementary therapists Training resulted in improved movement patterns and improved posture. 3. Griffin, M. & Neal, A. (2000) Perceptions of safety at work: A framework for linking safety climate to safety performance, knowledge, and motivation Fair Qualitative employees Review of Manual Handling Safety Guidelines from Legislations 4. Tullar, M.J. et al Occupational safety and health interventions to reduce musculoskeletal symptoms in the health care sector Excellent Systematic review Healthcare setting exercise interventions and multi-component patient handling interventions (MCPHI) were recommended as practices to consider 5. Blamire, G. (1995) An educational framework for training in manual handling Fair Manual Handlers Guide in training in manual handling 6. Cromie, J. E., Robertson, V.J., and Margaret O Best, M. O. (2001) Occupational health and safety in physiotherapy: Guidelines for practise Good Quantitative Physiotherapists Acknowledges the need for compliance with established ergonomic guidelines in the design of the working environment, and the job and systems of work 7. Hignett et al. (2007) Implementation of the Manual Handling Directive in the healthcare industry in the European Union for patient handling tasks Excellent Qualitative Healthcare and social care industry workers The directives given were followed from 1992 to 1996 with little research done. 8. Hignett, S. (2001) Manual Handling Risk Assessment in Occupational Therapy Fair Qualitative Occupational Therapists 9. Ndetan, H.T., Rupert, R.L., Bae, S., & Singh, K.P. (2009) Prevalence of musculoskeletal injuries sustained by students while attending a chiropractic college. Excellent Quantitative Chiropractor students There is a need for a manual handling protocol to prevent injury. 10. Nussbaum, M.A. & Torres, N. (2001) Effects of training in modifying working working methods during common patient-handling activities Excellent Quantitative Nurses Nurses who underwent training programmes obtained fewer injuries than those who didn’t. 11. Harkeness, E. F., Macfarlane, G. J., Nahit, E., Silman. A. J., and McBeth, J. (2004) Mechanical injury and psychosocial factors in the work place predict the onset of widespread body pain: A two-year prospective study among cohorts of newly employed workers Excellent Qualitative Manual Handlers Repeated exposure to mechanical trauma in the work place predicts the onset of widespread pain and determines the relative contribution of mechanical trauma compared with psychosocial factors. 12. Engkvist, I-L. (2008) Back injuries among nurses - A comparison of the accident processes after a 10-year follow-up Excellent Qualitative Nurses Nurses who had more task instruction encountered fewer injuries and back pains. 13. Clemes, S.A., Haslam, C.O, & Haslam, R.A. (2009) What constitutes effective manual handling training? A systematic review Excellent Qualitative Manual therapists Manual handling training is insufficient in reducing back pain and back injury. 14. Addison, N. and Burgess G. (2001) Compliance with the Manual Handling Regulations amongst a Random Selection of Small Businesses in England Excellent Quantitative Retailing to metals/engineering Manual handling improved working environment and reduced work loads 15. Owen, B. D., Keene, K., and Olsen, S. (2001) An ergonomic approach to reducing back/shoulder stress in hospital nursing personnel: a five year follow up Good Nurses Implementation of an ergonomics programme showed a reduction in shoulder and back pain, lost workdays and restricted/transitional days were also reduced. 16. Kneafsey, R., Haigh, C. (2007) Learning safe patient handling skills: Student nurse experiences of university and practise based education Excellent Quantitative Student Nurses Many student nurses undertook unsafe handling practices. 17. Massy-Westropp M., Rose D. (2004) The impact of manual handling training on work place injuries: a 14 year audit Good Quantitative Paramedical Aides Incidences of accidents decreased following introduction of manutention training of manual handling training 18. Hignett, S., & Richardson, B Manual Handling human loads in a hospital: an exploratory study to identify nurses perceptions Good Qualitative Nurses Manual handling tasks are assessed individually at a subconscious level of the practitioner 19. Swain, J., Pufahl, E. and Williamson, G. Do they practise what we teach? A survey of manual handling practise amongst students Excellent Qualitative Nursing students There was a theory-practice gap among students 20. Hignett, S. & Crumpton, E. (2007) Competency-based training for patient handling Good Qualitative Nurses Training resulted in a capacity to engage in more complex decision-making. 21. Pyves, G. 2000 No-hands massage:squaring the circle of practitioner damage Good Journal Article Massage therapists Altering the contact point of massage for deep structural work is essential for healthy practitioners 22. Knapik, J. 1997 The influence of physical fitness training on the manual material handling capability of women Excellent Quantitative Women in good health A physical fitness program can substantially improve the ability to lift in females 23. Resnick, M. and Sanchez R. (2009) Reducing patient handling injuries through contextual training Excellent Qualitative nurses All forms of training significantly improved the posture of the nurses 24. Bos, E.H.,Krol, B., Van Der Star, A., and Groothoff, J.W. The effects of occupational interventions on reduction of musculoskeletal symptoms in the nursing profession Good Systematic review Healthcare workers Combined interventions are effective in reducing MSD’s in the workplace 25. Schibye, B., Hansen, A., Knudsen, C., Essendrop, M., Bocher, M., Skotte, J. (2002) Biomechanical analysis of the effect of changing patient handling technique Excellent Quantitative Female Health Care Workers If the principles behind the techniques taught were applied, the risk of lower back pains are decreased 26. Bowley, H. and Holey, E. (2009) Manual therapy education. Does e-learning have a place? Good Quantitative Manual therapy practitioner An argument was raised that e-learning has a place in supporting and enhancing techniques for manipulative therapies 27. Lorme, K., Nagvi, S. (2003) Comparative analysis of low-back loading on chiropractors using various workstation table heights and performing various tasks Excellent Qualitative Chiropractors Workstation table height had a significance on lower back load. 655 mm of height created the least low-back strain. 28. Snodgrass, S. and Rivett, D.(2002) Thumb pain in physiotherapists: Potential risk factors and proposed prevention strategies Good Qualitative Physiotherapists Thumb pain has been a musculoskeletal complaint among physiotherapists. 29. Kuiper et al (1997) Epidemiologic evidence on manual materials handling as a risk factor for back disorders: a systematic review Good Qualitative Manual Handlers Relationship between lifting and back pain were found. Only a few quantitative studies were done. 30. Nelson, A., Matz, M., Chen, F., Sidderharthan, K., Lloyd, J., and Fragala, G. (2005) Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks Excellent Healthcare workers The development of a program resulted in the reduction of days and a decrease in unsafe handling practises Table 3 Quality Grading Grid Quality Grades Descriptor 1. Excellent Well-designed and executed study, with care taken to avoid bias. Very few weaknesses 2. Good Reasonable study design with minor flaws or omissions. Strengths outweigh weaknesses. 3. Fair Study has flaws and limitations in design. Conclusions to be viewed with caution. Strengths and weaknesses equally balanced. 4. Poor Significant problems with the study and/or major omissions. Weaknesses outweigh strengths. 5. Unstable. Study suffers from so many serious flaws that it is not useable as evidence. Very few strengths. Results Thirty relevant literatures were selected through the planned search strategy in obtaining the best relevant information for the discussion of the review. Nine out of 30 literatures were found out to be researches on what formal manual handling programmes should consist. Ten out of 30 literatures are pertaining to the results of the implemented formal manual training programmes whether they are effective or not in preventing work place injuries caused by manual handling. Finally, the remaining 11 out of 30 literatures are the researches on formal manual handling programmes aimed specifically at the area of injury from manual handling of patients. Two literatures are identified to be almost similar to the study being undertaken by the researcher. The study of Addison and Burgess (2001) investigated how small businesses in England complied with the Manual Handling Operations Regulations of 1992 since its implementation last January 1993. The other one, done by Clemes, Haslam and Haslam (2009), expressed concerns about the effectiveness of current manual handling training methods, and found out little evidence to support the efficacy of manual handling training. Outside Great Britain, Hignett et al (2007) investigated how a similar programme, the European Union Directive of Manual Handling, exerted influence in the healthcare industry, yet little research is done to rate its effectiveness, and little supporting evidences for its recommendation and it is also quite noticeable that only three countries of the EU have official guidelines on patient handling. In Australia, where the research is not as extensive as it is in Great Britain, more research is needed about the effectiveness of the Australian legislative requirements (Cromie et al, 2001) Some studies identified their own manual handling programmes other than the The Manual Handling Operations Regulations 1992. Eleven studies discussed the use of training and education in manual handling of patients, two of them focused on students (Nelson et al, 2005; Bos et al, 2006; Bowley and Holey, 2009; Resnick and Sanchez, 2009; Hignett and Crumpton, 2007; Swain, Pufahl and Williamson, 2003; Kneafsey and Haig, 2007; Nussbaum and Torres, 2001; Iakovou, 2010; Tullar et al, 2010; Blamire, 1995). Three studies proposed the utilization of ergonomic models or programs (Owen, Keene and Olsen, 2001; Tullar et al, 2010; Hignett and Richardson, 1995). Donnelly and Macmillan (2007) mentioned of the neuromuscular approach. Lastly, two literatures studied and recommended the use of exercise programmes (Clemes et al, 2009; Knapik, 1997). To further investigate on the factors that influence the success or failure of the formal manual handling programmes, the study will delve into physical, psycho-social, mental and emotional areas of well-being, at least to identify what must be modified in order to properly examine the effectiveness of the programmes. Four research questions shall be discussed based from the literatures gathered to identify the potential areas of weaknesses of exploring the effectiveness of these programmes, especially on the part of the practitioner: 1. How will formal manual handling training change the physical problems experienced by manual therapists resulting from their work? 2. How will formal manual handling training affect the mental and emotional states of manual therapists in relation to their work? 3. How will formal manual handling training affect the psycho-social states of manual therapists as regards work-related areas of their life? 4. What demographic factors affect the changes brought about by formal manual handling training on manual therapists? 1. Physical Areas The healthcare profession remained to be a physically-dangerous profession in terms of occupational hazards (Tullar et al, 2010). The most common of those injuries so far were back disorders (Kuiper et al, 1997). Almost all (91%) of physiotherapists acquire injuries that are musculoskeletal in nature due to manual handling of patients (Cromie et al, 2001), while nurses, especially those in paramedical field, are the most likely to be injured in manual handling (Massy-Westropp and Rose, 2004; Nelson et al, 2005). Massage therapists are also at risk for serious injuries (Pyves, 2000). It is then considered to be a major burden to society (Clemes, Haslam and Haslam, 2009). Harkeness et al (2004) explored the mechanical and posture exposures that might trigger the onset of musculoskeletal injury: Lifting more than 15 lbs. with one hand Lifting more than 24 lbs. with two hands Pulling more than 56 lbs Prolonged squatting Prolonged working with hands above shoulder level The likelihood of injury was varied in the chiropractic practice. Lorme and Nagvi (2003) compared the stress induced with different table height (465 mm, 665 mm and 845 mm) where chiropractors will be working with, and found out significant differences. The lowest level (465 mm) was noted to be the most stressful. The medium height (665 mm) was noted to be the least stressful for lumbar and thoracic manipulation, while the highest level (845 mm) for the cervical manipulation. They concluded that workstation height has a significant effect on low-back load. On the other hand, Ndetan et al (2009) noted that the Diversified, Gonstead and upper cervical adjusting techniques are the most related to injury. Exercise programmes might help in reduction in work-related injuries. Knapik (1997) studied the influence of physical fitness training programme to the manual handling capability of women, and noted the increased ability to lift a load from the floor to the height of the knuckles, and from the floor to the height of the chest, thereby suggesting a short-term physical program. Clemes, Haslam and Haslam (2009) suggested strength and flexibility training, yet needed further research to be used for long-term practice. Nussbaum and Torres (2001) examined its effects, yet obtained mixed evidence about its effectiveness. In addition to exercise techniques, Pyves (2000) discussed the possibility of no-hands massage, altering the contact point and body movements to prevent incurring injuries. Donnelly and Macmillan (2007) presented the neuromuscular approach and were found to be successful in detecting potentially-hazardous postures. To further investigate whether the ongoing programmes are effective, Engkvist (2008) compared how work-related accidents between a 10-year span, year 1992-1993 and year 2002-2003. He identified that most accidents occur during patient transfers, when patients having physical and psychological limitations are not cooperative, forcing nurses to use extensive manual handling. Considering the time span that the formal manual handling programme was implemented long ago, he also found out that nurses are more stressed, incurring more sick leaves due to injuries, and more often seeking medical care due to injuries in the year 2002 to 2003 than in the year 1992-1993. Does it suggest that Manual Handling Operations Regulations 1992 was not effective at all? Or does it need further revision, such as inclusion of exercise regimen? Nevertheless, physical injuries from manual handling causes burden to healthcare systems. Snodgrass and Rivett (2002) explored how the injury to the thumb triggered physiotherapists to leave their profession or change their specialty area. Cromie et al (2001) also noted that 1 out of 6 physiotherapists make a career change due to these injuries. 2. Psycho-social Areas Harkeness et al (2004) identified the psychosocial factors to be related with physical injuries from manual handling of patients. According to them, job satisfaction, social support and the state of the work being monotonous may predict the occurrence of symptoms of physical injury. Proper supervision can also minimise work-related injuries resulting from unsafe patient handling (Kneafsey and Haigh, 2007). An organization facilitating a safe culture demostrated lower postural risk (Hignett and Crumpton, 2007). Swain, Pufahl and Williamson (2003) noted the influence of healthcare team acceptance for student nurses to adapt the recommended techniques. C. Mental and Emotional Areas Another important area to be considered is the mental area, wherein it influences the psychomotor function. Training in manual handling techniques should begin as early as being student practitioners. Kneafsey and Haigh (2007) discovered that the same musculoskeletal pain was already experienced by student nurses, which is a threat to student’s safety, thereby safe manual patient handling is a must. Several studies dealt with the use of various education and training techniques minimise work place injuries. Bos et al (2006) suggested that education and training are effective in minimising work-related injuries, alongside with an ergonomic program. Blamire (1995) developed a planning package for training in manual handling, yet no further research was made for its feasibility in practice. Iakovou (2008) designed an evidence-based mobility curriculum to decrease the risk of injuries for nurses. Hignett and Crumpton (2007) identified the technique-training approach. Resnick and Sanchez (2009) formulated four training protocols which can reduce back injury. Researchers began to investigate how the mental area exerts influence in occurrences of injuries from manual patient handling. Swain, Pufahl and Williamson (2003) identified the theory-practice gap that prevents students from applying what they had learned. They also discovered the reasons for not using the techniques which were the unavailability of manual handling aids, lack of time and the needs of the patient. Clemes, Haslam and Haslam (2009) had also found out evidences that principles learned in training are not applied in the work place. Thereby, the issue in the mental area is not limited to the mental dimension per se, but extends to whether the principles learned are being applied to practice or not. Tullar et al (2010) therefore concluded that training alone is not effective in minimising work-related injuries. D. Demographic Factors The studies of Iakovou (2008), Swain, Pufahl and Williamson (2003) and Kneafsey and Haigh (2007) focused on student nurses while the rest of the literatures focused on adult healthcare practitioners who were manually handling patients. Most of the participants of their studies are residing from the United States, United Kingdom, Australia and the European Union countries. Little or none is known about the applicability of formal manual handling techniques beyond the countries stated, especially that non-English articles are excluded in the search strategy. The literatures included both male and female practitioners. While gender was not given much emphasis in these studies, Knapik (1997) focused on women. More studies are needed to identify the influence of specific demographic factors in the effectiveness of manual handling programmes. Discussion In light of identifying the effectiveness of formal manual handling programmes, the literatures suggest that there is weak evidence to support it (Harkeness et al, 2004). Despite many interventions had been proposed in effort to reduce work-related injuries, the field of health care remained to be a dangerous profession in terms of occupational hazards (Tullar et al, 2010). Nelson et al (2005) believed that the efforts in reducing work-related injuries remained unsuccessful over the past 30 years. It is uncertain whether there is still a major limitation of the programmes itself, or it was other factors which hinder the full efficacy of the programmes. No matter how good the programme is, it will not be proven to be effective if not either put into practice nor implement what is supposed to be implemented. The findings of Addison and Burgess (2001) revealed that even though the companies under their study claimed full compliance to the Manual Handling Operations Regulations 1992, there are 38% of them who remained unaware about it, while 46% of them did not even performed an assessment on how should they implement the programme. Thereby, an issue of non-compliance and non-awareness prevents the programme to manifest its efficacy in minimizing work place injuries at all. It is also equally useless if, despite knowing the necessity of doing it, it will not be put into practice (Swain, Pufahl and Williamson, 2003) and not being taken seriously (Kneafsey and Haigh, 2007). Physical, psychosocial, mental and emotional areas are indeed factors to consider in evaluating the effectiveness of a formal manual handling programme. By this time, no research supported the positive influence of formal manual handling programmes in minimising work-related injuries in a long-term base. Only Engkvist’s study (2008) provides light, but it appears that it proves otherwise wherein the programmes became ineffective on its own without considering other factors that might hinder their success. Evidences on the successful manual handling techniques that effectively minimised work-related injuries remain weak (Harkeness et al, 2004; Kuiper et al, 1997), and further studies are highly recommended, although the application of recommended patient handling technique provides better promises than none at all (Schibyye et al, 2002). References Addison, N. and Burgess, G. “Compliance with the Manual Handling Regulations amongst a Random Selection of Small Businesses in England.” The Annals of Occupational Hygiene 46.2 (2002):149-155. Blamire, G. “An Educational Framework for Training in Manual Handling.” Physiotherapy 81.3 (1995): 149-153. Bos, E. 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The Manual Handling Operations Regulations 1992. No. 2793. Crown copyright. http://www.legislation.gov.uk/uksi/1992/2793/contents/made. Date accessed: 06.11.2010. Tullar, J. et al. “Occupational Safety and Health Interventions to Reduce Musculoskeletal Symptoms in the Health Care Sector.” Journal of Occupational Rehabilitation 20.2 (2010): 199-219. Read More